1040 N ANAHEIM BLVDPermit Types
BLD ELE MEC PLM
X X X X
Permit Number: 110Y022-05443
Issued: 02/13/2023
www.anaheim.net/building
(714)76511626
Quarter Section: 70
CITY OF ANAHEIM
BUILDING DIVISION
200 S. ANAHEIM BLVD.
(714) 765 - 5153
Site Address: 1040 N ANAHEIM BLVD 1-2, ANAHEIM, CA 92801
Legal Description: N TR 17846 BLK LOT 1 TRACT NO 17846 LOT 1 POR OF L
APN:26715134
WORKER'S COMPENSATION DECLARATION:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OR THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a certificate of consent to self -insure for worker's compensation, issued by the Director of Industrial Relations as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.
I have and will maintain worker's compensation insurance, as required by Seclion 3700 of the Labor Code, for the performance of the work for which
this permit is issued. My workers Compensation insurance carrier and policy are:
Cartier. OLD REPUBLIC INSURANCE COMPANY Policy No.: MWC31414022 Expiration Date: 9/1/2023
Name of Agent:
Phone No.:
I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the
worker's compensation laws of California, and agree that, d I should become subject to the worker's compensation provisions of Section 3700 of the
Labor Code, I shall forthwith comply with those provisions.
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Signature of Applicdfft
DECLARATION REGARDING CONSTRUCTION LENDING AGENCY:
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Date
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is Issued
(Sec.3097.Civ.C):
Lender's Name:
Lender's Address:
LICENSED CONTRACTOR'S DECLARATION:
I hereby affirm under the penalty of Perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
41— L"
Contractor Signature
NUMBER EXPIRATION DATE LICENSE TYPE (S)
728102 04/30/2024 B, B. B, B. B. B, B, B. B, B, B, B
211 2/2,3
Date